(I published this Nov. 7, 2006 on my prior web log "Systems Thinking in Public Health."
I keep referring to it, so I'm republishing it here.)
Above - Amish Barn raising by "heyburn3"
"Houston - we have a problem!" - Below is a graph I made to illustrate the idea that the complexity of issues we face in public health continues to rise exponentially, but the mental capacity of the world's brightest problem solver has largely hit a plateau - at a value smaller than required to address these difficult problems.
I could just say that, but it doesn't convey as strongly the idea that the old world will NEVER come back. Once these lines have crossed, they're crossed forever. We will just get more and more outclassed by our problems if we attempt to solve them as individuals.
With that prelude, here's a very different view of a possible answer to the question of what the most important problems are in US public health today.
But first, a metric. I'll suggest, for discussion, that one binary outcome measure captures a great deal, and a quantitative measure would be the probability of the outcome occurring. The outcome I have in mind is whether mankind will successfully populate other planets or not. That outcome will definitely not occur if any event occurs which terminates the species Homo sapiens. So, in some sense, this is a mortality measure, but the mortality is of the entire species, not of individuals in the species.
Various "hazards" come to mind that could terminate the species, ranging from release of weaponized smallpox to global warming to World War III to a large collision with large asteroid. While the other hazards may be somewhat controllable, a large asteroid collision is a purely stochastic event, that will occur sooner or later, we just don't know when. By this metric, then, the "problem" that the planet cannot support China and India rising to the level of consumption that the US has shown cannot be fully resolved by cutting back on consumption. The risk of total extinction does not go to zero and the graph intersects the Y axis above zero, not the X axis above zero, compared to the ones we had in lecture.
Asteroids, however, may be a million years away. Global warming has already started, and bio-terrorism could be here already today, for all we know. Or, there may be new risks, that no one has even thought of. Degradation of the environment is occuring at an increasing rate, and destabilization of the biosphere could also occur within our lifetimes.
Those, however, in my mind are hazards, not "issues". The issues, to me, are more in what public health is doing, or is not doing, to address those hazards.
The three most important issues, in that they seriously impact the odds of survival of us all, or of our progeny and species, in my mind are the following:
1) Public Health needs better "eyes".
We need substantially stronger ways of working together with each other to do research and understand problems. We need much stronger tools that assist in understanding complex multi-level feedback loops, and gaining insight and intuition as to what types of behaviors these systems exhibit, and what types of interventions are possible. The complexity is often beyond that a single human can grasp, but we need to figure out how to grasp it collectively, because this is the shape of the systems we're studying. We need concepts that go upwards, not downwards from humans - looking for "macrobes" instead of microbes, i.e., for pathologies that multi-human systems exhibit, and how to recognize parasites, blindness, auto-immune disease, system failure, and other familiar medical analogies in these multi-person systems. Failure of the parts to work together as whole is something medicine understands, but the tools haven't been extended to, say, corporations, NGO's, FEMA, the US Government as a whole, etc.
2) Public Health needs better "muscles".
The rift between corporate America and Public Health is, in my mind, coming close to killing us all, all by itself. Over the last 100 years, as Laurie Garrett has documented so well, Public Health globally has been battered, assaulted, sometimes gutted, and reduced to the point where less than 2% of our country's health care dollars go towards prevention. At the same time, GM is going bankrupt claiming health care costs are killing it. With the economic downturn and Asia's rise to power, corporations are going to be pulling out the "jobs" card, and begging for reduction on restrictions to their pollution so they can be "competitive globally." That, in my mind, isn't a problem that can be solved from the outside by messages or education or regulations, especially since corporations control the regulatory bodies - with the unemployed army backing them up.
I see another way this could play out. Public Health becomes the world experts on the ailments of multi-human systems, including corporations. We figure out how to make corporations vastly MORE successful, so they don't NEED to cut corners, pollute, and cut jobs in order to survive. This is my own view, but I think there are some bad CEO's, but most would actually rather play golf and be well accepted in their towns than have heart attacks and be considered evil-doers. GM honestly doesn't understand, at the top, what most of the workers on the ground floor can easily see. This is a typical large organizational blindness, and basically a hyper-medical problem. It should be something Public Health can address, in partnership with GM.
Only if public health is seen as part of the solution, not part of the problem, will the rest of our agenda have any visibility or traction in board rooms. And we need those muscles, of CEO's like Bill Gates, to tackle the hard problems, like how to stop World War III from being inevitable.
3) We need better ways to work together, and to help others to work together.
The bright light in all this is that there is a huge untapped resource available, by which I mean the global internet and the deployment of a billion computers, cell phones, PDAs, and other devices connected to it. 1 Gigahertz processors sit idle on desktops, or are used for email, despite having more processing power , collectively, that's going to waste, per second, than the entire US computing industry used per year in 1980 or something like that. Most of these machines, today, are networked and can communicate easily with each other, while other things are going on. Public Health utilizes what, about 0.000001% of that, to assist in our interventions and agenda?
I'm not talking about "health records", or learning Microsoft Office - I'm talking about getting people organized into cross-supportive clusters that facilitate behavior modifications and life-style changes, such as web-log teams - very popular among teenagers today. Or attaching almost any quality bio-surveillance tool to computers or phones, to monitor keystrokes or voice stress, to collect epi-data on impairment clusters or dynamics that occur in time-frames of minutes to hours to days to weeks to months, to fill in the gaps between office visits, to detect adverse events of new drugs without anyone having to fill in a form, to detect real-time, a drop in productivity in a whole office building floor or deck of a ship due to an unknown and unexpected silent event.
We are told, cajoled, asked, instructed, and force to "work in groups", but the instructions as to how to make that process actually both successful and enjoyable are astoundingly thin. Most people I know just dread "group work". Why is that? Why can't we get a better work product out of a committee than we do out of an individual?
We laugh at those situations, or write them off, but if you multiply that times a million, you end up with FEMA's "preparedness" for Katrina. This is the stuff of the "Dilbert" comics but it should be the stuff of public health, in my mind. This is what's killing our companies, our NGO's, our benefactors investments, our economy, and forcing companies to skimp where they should be doing more.
So, is the health of multi-human persistent groups an appropriate subject for "public health"? I vote yes. Does corporate health affect their tendency to pollute? I'd say that's a good hypothesis to study. Does the term "corporate health" mean something more than an analogy? Is there effectively an entity with a "life of it's own" in a corporation that is above and beyond the humans that make up that corporation, that has a "health" and therefore has "health problems"?
Interesting questions.
If there were, which specialty area would be the one to study it and fix it?
collaboration
cooperation
complexity
cscw
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